Corus plexus = CSF

Foramen of Lusaka + openings for fluid to flow

Foramen of Magendie = if these are blocked ^ICP
Meningitis = ^ ICP and compression
^ICP = Swelling = tentorium herniation = downward pressure = <bp/<resp = death
Corus plexus = CSF
Foramen of Lusaka + openings for fluid to flow
Foramen of Magendie = if these are blocked ^ICP
Meningitis = ^ ICP and compression
^ICP = Swelling = tentorium herniation = downward pressure = <bp/<resp = death
 Foreman of Magendie
Foreman of Lushka
Cranial Nerves

12 pairs of CNs
Primarily innervate the
HEAD & NECK except
for CN X which extends
to the thorax &
abdomen
Functions:
1. Sensory
2. Motor (Somatic)
3. Parasympathetic
Sensory-Somatic Nervous System
I. Olfactory = Smell
II. Optic = vision
III. Oculomotor = pupils = constrict = ^ eyelids
IV. Trochlear = down/inward eyes movement
V. Trigeminal* = forehead,
VI. Abducens = lateral eye
VII. Facial
VIII. Acoustic/ Vestibulocochlear
IX. Glossopharyngeal
X. Vagus
XI. Accessory/Spinal
XII. Hypoglossal
Sensory
I. Olfactory = Smell
II. Optic = vision
VIII. Acoustic/ Vestibulocochlear = hearing (cochlear) balance (vestibular)

Motor
III. Oculomotor = pupils = constrict = ^ eyelids
IV. Trochlear = down/inward eyes movement
VI. Abducens = lateral eye movement
XI. Accessory/Spinal = sternomastoid / upper trapezius
XII. Hypoglossal = tongue movement

Both
V. Trigeminal* = face, surface of eye (corneal) mastication
VII. Facial = taste anterior tongue, facial movement
IX. Glossopharyngeal = sensation of tongue and pharynx ^ & swallowing
X. Vagus = lower pharynx and larynx, soft palate movement, Para sympathetic
The movement of the eyeballs : Motor
III. Oculomotor = pupils reaction = constrict = ^ eyelids
IV. Trochlear = down/inward eyes movement
VI. Abducens = lateral eye movement = GAZE with superior/medial/inferior rectus and
oblique muscle
Assessment : Ask pt to follow your finger through cardinal fields
GAZE: PERRLA : pupil = round, reactive to light and
accommodation to light
Both
V. Trigeminal* = face, surface of eye (corneal) mastication
Sensory: forehead cheek and jaw =
assessment : Close eyes / pin on face = feel touching
Motor: clenching and chew of jaw = dentist numbs for root canal
*** pimple infection dont touch = trigeminal neuralgia = tickdelarou
VII. Facial = taste anterior 2/3 tongue, facial movement
Sensory: taste = sweet/salty/sour
Motor: Smile and facial movement
Assessment : puff of cheeks
IX. Glossopharyngeal = sensation of back of tongue and pharynx ^ swallowing/gag
Sensory: taste = Bitter posterior tongue
Motor: Swallowing/gagging reflex
X. Vagus = lower pharynx Gag and larynx, soft palate movement, Para sympathetic
Sensory: partial cells = ^ HCL in stomach *****HARD TO ASSESS*****
Motor:
Favorite
XII. Hypoglossal = tongue movement
Mr. Phoenix fav. / Ice-cream
 # Name Type Function

I Olfactory S smell

II Optic S vision

III Oculomotor M extraocular eye movement;pupillary reaction

IV Trochlear M upward & downward eye movement

V Trigeminal B sensation from the face & mouth; mastication

VI Abducens M lateral eye movement

VII Facial B taste;saliva & tears production; facial expression

VIII Acoustic S hearing & balance

IX Glossopharyngeal B taste; swallowing; tongue movement; salivation

X Vagus B swallowing; digestive,respiratory, cardiovascular

activities

XI Accessory M Head & shoulder movement

XII Hypoglossal M Tongue movement

Olfactory Optic Oculomotor
Trochlear
On Old Obando Tower
Top A Filipino Army
Guards Villages And Huts.

Abducens
Trigeminal
Some Say Marry
Facial Money But My Brother
Said Big Business
Makes Money.

Acoustic/Vestibulocochlear
Still can't
remember the
Glossopharyngeal names of the
cranial nerves?

Vagus

Hypoglossal Accessory/Spinal
CN 1 is from Frontal lobe
Midbrain
CN 2 is from the Occipital lobe
CN 3 & 4

Pons
CN 5, 6, 7 & 8
Controls BP
^ICP = sharp ^systolic no
change is diastolic
= wide pulse pressure
= bradycardia
= Cushing triad
^SBP/ <pulse <resp

Respiratory center
^ICP = depression of Resp

Medulla Oblongata
9, 10 ,11, & 12
Vomiting center (9,10)

Brainstem
CN I : OLFACTORY

Ask client to SNIFF &

identify aromatic
substances.
 CN II : OPTIC

Use of Snellen Chart

Ask client to read
printed materials
 CN III : OCULOMOTOR
Assess directions of
gaze by asking client to
follow moving objects.
Measure pupillary
reaction to light reflex
& accommodation
CN IV & VI: TROCHLEAR
and ABDUCENS

Assess directions
of gaze by asking
client to follow
moving objects.
CN V : TRIGEMINAL
Corneal reflex
Assess light touch & pain
sensation across the
face
Opening the mouth
against resistance &
moving the jaw from the
side to side
 CN VII : FACIAL
Ask client to smile,
whistle, frown, puff out
cheeks, & move
eyebrows
Have client identify
salty & sweet tastes on
front of the tongue
CN VIII : ACOUSTIC
Air & bone conduction
Ability to hear spoken
word
CN IX : GLOSSOPHARYNGEAL
Ask client to identify
sour, salty or sweet
tastes on back of the
tongue
Elicit gag reflex and
assess swallowing
reflex.
Ask to speak or cough.
 CN X : VAGUS

Ask client to say ah

and assess for
movement of the
palate and pharynx
Elicit gag reflex
Ask client to speak.
CN XI : ACCESSORY

Ask client to
SHRUG shoulders
& turn head
against resistance
CN XII : HYPOGLOSSAL

Ask client to stick out

tongue and move it
from side to side
 Trauma = car accident / whip lash
= coup (head forward)
= counter coup (head back)
Contusion Concussion
Jarring Jarring
After accident is Awake Knocked out
hyperactive No brain lesion
Lesion on the the brain
Symptoms come later after
SNS goes away /
Lesions
adrenaline goes away Meningitis
<LOC Aneurism
+ Fluid = +Pressure
+ my head hurts
+ headache
C O M P O S U R E
Ex. Bleeding, Encephalitis, V. accident, Tumor = Compression ^ICP
C/O headache = <LOC... How would you act?
Consciousness = <LOC = verbal, tactile, painful stimuli
Orientation? Where are you, name, time/date/day or night, reason there, raising
voice/delayed veral = letharic LOC, superus = falls asleep after arousal,
Oxygenation = RA / o2 / hypercapnia /hypercarnia = false o2 / hemoglobin 1gr/1.3cc
Need 20cc/100ml of blood = adequate o2 to the body 90/60/30 rule
Motor Function = Parietal part of the brain
Pupils = Wait check after motor / will not see change if the brainstem is not affected (
Ocular Movement =
Signs =
Urinary Output =
Reflexes =
Emergency =
***you can elevete the head 30 only and o2***
Parietal part of the brain controls muscles = could aspirate and ^ICP
If the head of the bed is too high it can effect CPP
Cerebral profusion pressure = the amount of pressure need to blood flow from the heart to the
brain
^Co2 = vasodilatation and ^ICP
Room not too bright / dark
****VS are the last thing to change with ^ICP****
Consciousness
FORMS OF LOC
STIMULI
Verbal Tactile Pain
VERBAL
VOICE Conscious (+) (+) (+)
SHOUT Lethargic (+)* (+) (+)
TACTILE Stuporous ( -) (+)* (+)
TOUCH
TAP/ SHAKE Semi-Comatose(-) (-) (+)
PAIN
Comatose (-) ( -) (- )
SUPERFICIAL
DEEP * delayed reaction
Orientation? Where are you, name, time/date/day or night, reason there, raising
voice/delayed verbal = lethargic LOC

Stuporous = falls asleep after arousal

Semi comatose = painful stimuli = nailbed = withdrawal

Comatose no response to stimuli
Semi comatose = painful stimuli = nailbed = withdrawal
sternal rub
orbital pressure if no damage
pinching muscle group
= withdrawal
Decorticate = defused hypoxia of the cortex / damage in the cerebral cortex
Decerebrate = parietal track / brain stem
Lowest is 3

Below 7 is low /bad

Incomprehensible
Sounds = moans
= unable to
speak
=2
Inappropiate words
=wordsalad
=3
 The Brain

Motor Function = Parietal part of the brain

Decerebrate = parietal track / brain stem
 MUSCLE STRENGTH GRADING
Motor Function
Assess integration of Grade Description
consciousness & voluntary
movement. 0 No contraction
Look for purposeful or non- 1 Slight contraction
purposeful response.
Assess muscle tone, size, 2 Full passive ROM
strength. 3 Full ROM
Observe for symmetric, 4 Full ROM against
spontaneous movement of some resistance
arms & legs 5 Full ROM against
full resistance
Weakness on the Right = lesion on the Left side of the brain lesion
5/5 R arm 3/5 L arm

5/5 R leg 3/5 L leg

Purposeful movement not reflexive = have grab with index finger and thumb
Extend both arms = the weak side will pronate and fall = lesion of the opp side of
brain
Above the neck = same side lesion = face drooping = ipsilateral
Below the neck = lesion on the opp side = contralateral
Semi comatose = compress the nailbeds on both sides = dcor/decelabrate
Ocular Movement
I Semi/Comatose= against the direction of head
= supine = doll eyes closed
Assess for deviation to one side. = move head Left eyes go Right
Also assess voluntary & spontaneous movement =partner= hold open and turn
GENERAL IMPLICATION:movement
Controlled by:
III= papillary control = reaction to light reflex &
accommodation
IV= gaze = following moving objects.
VI=gaze= superior/inferior rectus (up/down)

IF the eyes bob = problem = ipsilateral lesion

Meningitis = eyeballs Left = lesion on the right
Pupils = brisk reaction Hemmorage = lesion and eyes on same side!
Anticholinergic drugs = Scopolamine
= 1 bigger than the other
Inotropic bromide
= normal is 2-6mm (eraser)
=dialation of the pupils
= anisocoria = ascemtrical ok
You cant see, pee, spit or shit
= or a symptom
Brain stim is affected = Mid brain = assess using pen light for brisk reaction
PERRLA = pupils equal, round, and reactive to light and accommodation
Fixed and dilated = diffused hypoxia to the cortex
Pin pointed (both)= damage to the pons
 Eyes
Fixed and dilated = diffused hypoxia to the cortex
Pin pointed (both)= damage to the pons
Anticholinergic drugs = Scopolamine
Inotropic bromide
=dialation of the pupils
Drugs and Pons = pinpoint pupils
 Twin Risks: want 95% o2
Hypoxia
Hypercapnia = carbon dioxide
false o2 / hemoglobin
1gr/1.3cc
Need 20cc/100ml of blood = adequate o2 to
the body
6L = 6000ml CO /. 100ml = 60
60x 20cc = 1200cc of o2

90% o2 = 60mm/po2
60% o2 = 30mm/po2

Dont wait for VS change

Better to over-react than under react !!!
Tentorium at the base is hollow
If swells = tentorium herniation

*** if pressure is not relieved within 30-60 min the pt will die***
VITAL SIGNS Late Signs

Sharp systolic pressure goes up and

leaves behind the diastolic
<HR
<RR
=death
Normal is 30-40mm difference
30-60min = death if ^ICP is not releived
May have projectile vomiting
Headache
Papilledema (opitic nerve not seen by
the naked eye)
 Headache

Projectile
Vomiting

Papilledema
Babinski reflex controlled by L4 & L5, S1 & S2
Normal = toe flexion (except in infant)

Abn = Dorsiflexion of big Toe, Fanning of Little

Toes (except in infant)

Pyramidal Tract / Upper Motor Neuron Damage

or brain stem

Spinal cord is the hub

Cord to brain is upper motor
+ Babinski =
Cord to periphery is lower motor
problem with upper motor

Corneal Reflex Pons = 5th CN = clap and blink=corneal reflex

trigeminal
Medulla
Gag/ cough Reflex Medulla
CN IX Glossopharyngeal
CN X Vagus
Babinski reflex
 Pupillary Reaction Key
to Brainstem Function
Normal = 2 6 mm
PERLA / PEARL

Hypoxia Fixed and Dilated Bilaterally

Pons Injury Pinpointed/Non-reactive

Drugs:
1. Atropine = pupillary dilation

Eye Dr
2. Morphine= pupillary constriction

Cocaine
Pons injury = non reactive Demerol
Urinary Output
Urine Sp. Gr. = 1.010-1.025

Compress the brain = compressing

the Hypothalamus
<1.010 Sp Gravity

Controls water holding mechanism

^urine volume
= diluted urine
= blood volume down
= <MAP
= <SV
Mannitol = hypertonic solution = <CO
= osmosis = <BP
= lower to higher concentration = <CCP blood flow to the brain
***moves fluid into the vascular space***
***and can be excreted through the kidneys*** ***Must Control ***
*** look out for crystals = bad solution*** Further hypo perfuse
Has to be given as a fast drip = bc it will no Hypoxic
longer act as a hypertonic = open it up brain
 Nursing Interventions To Prevent
Increased ICP
Positioning 15 no more 30 Pain, discomfort, non-therapeutic
touch
smallest needle possible
Movement = Headache
do not over inflate cuff
Log roll as one unit = get help
Dont move unless necessary
Fever= control
Uncontrolled hypothalamus =
Hypoxia=carbon dioxide/false
Tylenol will not control the temp give
o2 reading = acidosis
IV not suppository
^ICP = seizures
Suctioning= Hyper o2 b/f and after.
No suppository / enema
Never suction during inserting.
Only suction as long as you can
hold own breath Valsalva Maneuver = closed glottis
No suppository / enema
Noise= limit stimuli = further from Constipation = give IV / peg tube/ng
nursing desk. Stool sofener
Laxatives